METABOLISM IN RESPIRATION AND CIRCULATION 549 



quotients found in moderately sick patients do not indicate any changes 

 in the intermediary metabolism, but it is again quite possible that they 

 may occur in severely sick cases and evidences of them may be sought in a 

 study of metabolic products in the blood and urine. The observations on 

 carbon dioxid appear to indicate a moderate grade of acidosis in severely 

 decompensated cardiac patients, and this is probably correctly considered 

 as secondary to incomplete combustion due to oxygen lack. The carbon 

 dioxid retention described by certain authors in pulmonary disease, and in 

 some cases of acute cardiac decompensation may be a factor in producing 

 dyspnea, but only through this would it have any important relation to 

 the metabolism. 



It has been suggested above that other indications of a disturbance of 

 metabolism in the diseases of the circulation and respiration might also 

 be derived from studies of the non-volatile products of metabolism in 

 the blood and urine. It is unfortunate that few analyses of the blood in 

 these conditions have been published, and that complete metabolism ob- 

 servations, with balance sheets of the intake and output, are almost lacking. 

 Tileston and Comfort (a) determined the total non-protein nitrogen and the 

 urea nitrogen of the blood in a large series of cases, and found normal 

 values in compensated valvular heart disease, aortic aneurism, acute peri- 

 carditis with effusion, and acute endocarditis. In cases with cardiac in- 

 sufficiency the figures were normal, or slightly elevated, except in one 

 instance with marked failure of compensation in which the total non- 

 protein nitrogen was TO mg. per 100 c.c. of blood a few hours before death. 

 The increase of blood nitrogen in severely decompensated patients is 

 easily explained by the impairment of renal function owing to imperfect 

 circulation. According to O'Hare(fr), the urea nitrogen content of the 

 blood in patients with vascular hypertension is normal unless there is an as- 

 sociated nephritis. Rowe(a) investigated the non-protein nitrogen, and 

 also, by a refractometric method, the total protein, albumin, and globulin 

 content of the serum in various diseases. In cardiac decompensation, with 

 or without edema, there was a decrease of total protein, though not to the 

 same extent as in chronic nephritis with edema. The percentage of 

 globulin and non-protein nitrogen were slightly above normal, but in 

 one case of bronchial asthma there was moderate elevation of the non- 

 protein nitrogen with normal serum proteins. In conditions of venous 

 stasis he found the total protein to increase, with a greater increment of 

 albumin than globulin and no change in the non-protein elements. 



Very little work has been done on the constituents of the urine in the 

 diseases of the circulation and respiration, except in the case of pneu- 

 monia and tuberculosis, in which the elements of fever and toxemia enter. 

 One might expect to find an increase in nitrogen excretion in association 

 with dyspnea, especially since it has already been shown that there may 

 be a considerable increase in basal metabolism. The earlier literature (see 



